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HomeMy WebLinkAbout0139 CAPES TRAIL - Health (2) 139 , Capes Trail Y W. Barnstable P q- 088 006001 5, fA F TOWN OF BARNSTABLE L&ATION ��j� 1�`�S r1Ca.c�L SEWAGE# To Vi; LAGE Ulo. ,�i1SRc�bi.� ASSESSOR'S MAP&PARCEL 061-1 00/ NAME&PHONE NO. 1'7-7 SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type)"'�t`s (size) 1000 NO. OF BEDROOMS OWNER. \ ►.tea ec--a PERMIT DATE: COTOWFAFef DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Ca e's Trail Driveway g .. L�aPAg� 36 20 r - 4 81 d COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 4 DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 139 Cape's Trail OO b�,�j —00 & ~ West Barnstable MA 02668 Owner's Name: Theresa Savini&Jonathan Brand Owner's Address: Same Date of Inspection: August 16,2006 Job#06-210 s Name of Inspector: PATRICK M.O'CONNELL } Company Name: SEPTIC INSPECTION SERVICES CO. t Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 t ' Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �v���°�MOFZ/i Passes ?o '•;yG Conditionally Passes TrtIC N Needs Further Evalua ion by the Loci Approving Authority = M. F NN 1 c Inspector's Signature: Date: 8/16/06 ''�,,�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healtfi b / DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 inspector and the system owner shall submit the report to the appropriate regional office of the d or greater,the ins e y P gp g p DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Observed leaching pit at 2/3 capacity and septic tank scheduled to be pumped following inspection. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other. failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds . indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. f Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): N/A well water Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped two years ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1993 Were sewage odors detected when arriving at the site(yes or no): No i Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet invert.Recommend pumping tank every two to three years to properly maintain system. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or high stains present,liquid level at bottom of single outlet invert. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries,number: _leaching trenches,number, length: _leaching fields,number,dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Observed 4 feet of standing water in 6 foot deep Ot CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): I f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Ca e's Trail briveway 36 20 81 4 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: 139 Cape's Trail,West Barnstable Owner: Theresa Savini&Jonathan Brand Date of Inspection: August 16,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: _Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el.40 and topo map shows property at el. 150. „ t , , J i _ .`Sz COMM-ON OF I ASsAC 1-LSETTS EXECUTIVE OFFICE OF ENVIRONI4�NTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO ECTMEIVED MAR 2`0 2002 TOWN O B BLE- DEPT. TITLE.5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORtM PART A CERTIFICATION Property Address: 13 q of ez S �2 s4 1 / PARCEL ' �O�C►®� �/c ST ,Qi9/I n/S TA 13� e LOT 4- Owner's,Name: T 2 k Owner's'Address: S�9-� r Date of Inspection: 3 Name of Inspector: (please print) �j9Y�� �izcF}.9-,q c3 el*v Company Name: Mailing Address: Pd aoX 919-1 11YA 12/,41 is .19 0—L.-- Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the.information reported below is true,accurate and complete as of the time of the inspection.The inspection was.performed based on my training and experience in the proper function and maintenance of on site sewage.disposat systems.-I am a DEP approved system inspector pursuant to Sea' a 15.340 of Title 5(310 Clint-15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date* 3 �� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,0,00 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments "This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection.does not address flow the system will perform in the.future under the same or different conditions of use. Page 2 of 1 I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTA V ASSESSMENTS SUBSURFACE SEWAGE DISPOS SYSTEMEqSPEMON FORM PART A CERI IFICATI®N(continued) Property Address: /3 (-4P S J� �- �/F'S7 �12.-1s74,6A Owner:/ z 2-2 i' 5 9 U/d/ Date of Inspection. 3 Z/ o Inspection Summary: Check A,B,C,ID or E[ALWAYS complete aIi of seta D A. Sys°ste t,found-any,marniatiAn"wMich es: i h indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exsst'*Arty fiilure criteria not evaluated are indicated below_ Comments: TOM B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"p ease explain. fi The septic tank is metal and over 20 years old*or the septic tank(whether metal.or not)is structurally unsound,exhibits substantial infiltration or exhItration or tank faRm is hnminenL System will pass.inspectim ifibe existing tank is replaced with a complying septic tank as approved by the Board of health. *A metal septic tank will pass inspection if it is structurally sound,not leakrnQ.�and if a Certificate of Compliance indicating that the tank is less than 20 years old is available_ ND explain: Observation of sewage backup or break out or bigh static water.level in the distribution-box due to brbk-as or obstructed pipe(s)or due to a broken,settled or.uneven distribution box.System will pass.inspection if(with approval of Board of Health): broken pipes)an replaced obstruction is removed distribution lox is ICWJW-sir named. ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: Page 3 of I I OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISF®SAE SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3`J Cq to S Gz ► �- CfJ�ST' Ae Owner: le-R i A v i Hate of Inspection: C. Further Evaluation is Required by the Board of health: Conditions exist which require nor ra tuation by th Board of Health in order to determine if the systemis failing to protect public health, safete en onment. 1. System will pass unless Board of Health de mines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner whi ill protect public health,safety and the en3dronment: — Cesspool or privy is within 50 feet o a surface water — Cesspool or privy is within 50 feet of a borderin vegetated wetland_or a salt marsh 2. System will fail unless the Board-of health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,saf and environment: _ The system has a sep *c tank and soil absorption system(SA and the SAS is within 100 feet of a surface water supply or trib tary to a surface water supply. The system has a septic and SAS and the SAS is w' hin a Zone I of a public water supply. The system has a septic tank nd SAS and the SAS s within 50 feet of a private water supply well.. _ The system has a septic tank an AS and the AS is less than 100 feet but 50 feet or more froth a private water supply well**.Method to det me distance "This system passes if the well water anal is,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds di tes that the well is free from pollution from that facility and the presence of ammonia nitrogen and trate m ogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy the analys must be attached to this form. 3. Other: i Page 4 of I I OFFICL4,L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS TS SUBSURFACE SEWAGE DISPOSE.SYSTM.PiSTECTION FORM PART h CERTIFICATION(cow) Property Address: 13 --7— b Gr/c Owner:/9 Ae,?i S�vrti s Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool i Discharge or ponding of effluent to the surface of the ground or surface-waters due to an overloads or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert-due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less_than 6"below inventor available volume is less than'fz day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe{s}.Number of times pumped s Any portion of the SAS,cesspool or privy is below high ground water elevation. — Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water-quality analysis.[This system passes if the well water analysis, performed at a IDEP certified laboratory,for conform bacteria and volatile organic compounds indicates that the weft is free from pollution from that facility and the presence-of ammonia nitrogen and nitrate nitrogen is equal to or lm thau:5 ppn,provided that no other ftflure cngwi2 are triggered.A copy of the analysis m be aMcheal_to-this.fo11%j (Yes1No)The system fails.I have determined that one or mare of the above failm criteri exist as Y-0— described in 310 CMR 15.303,therefte-the system fails,The system o mer.should contact the Board of Health to determine what-will be necessary to correct the failure. E. Large Systems: To be considered a large system the system- a amity with:a design:low of 10,000 gpd to 15,000 gld- You must indicate either"ye ye 'or`°no"to each the following: (The following criteria apply large systems• addition to the criteria above) yes no the system is within 40 feet a surface drinlQng water supply — — the system is within 200 of a tributary to a surface-drinking water supply — the system is located ni gen sensitive area(Interim Wellhead Protection Area—I�&'PA)or a upped Zone II of a public w r supp well If you have answered"yes to any question in Section E the system is considered a significant threat,or answered " owner r operator.of an large system considered<a des m Section D above the large stem has-faded:The.o o p y arg y ge system significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CHECKLIST Property Address: 13 _�9�'__5 A2,4 al z Si A 4 Owner:le,2,L Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? i .Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth'•of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is-unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FOCI-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWACEDISPOSAL SYSTEM PISPEMONFORM PART- € SYSTEM INFORMATION R Property Address: /3 Owner: Date of Inspection: LGW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): -3 DESIGN flow based on 310 CMR ISS203(for example: 11.0 gpd -#of bedrooms):3 3 Number of current residents: _ Does residence have a-garbage grinder(yes or no)- Is laundry on a separate sewage system(yes or no):/V lif yes separate-inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):/ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: lVc, w COMMERCIALIINVDUSTRIAL Type of establishment: Design flow(based on 310 MR 15.203): d Basis of design flow(seats! sons/sq Grease trap present(yes or no): Industrial waste holding tank pre t(yes or no):_ Non-sanitary waste discharge o Title 5 system(yes or no): Water meter readings,if av ' able: Last date of occupancy/ e: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. 152 G(/iy Was system pumped-as part of the inspection(yes or no).-IV If-yes,volume pumped:_gallons--How was cluantity.pumFerfdetermined?- Reason for TYPK-OFSYSTEM-. _G Septic tank,distribution box,soil absorption systems _Single-cesspool 6verflow cesspool Privy _Shared system:(yes or no)(if yes,attach previous-inspection records,if any)- innovative/Alternative technology:Attach aeopy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEPP-approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 14793 9g �Sr•�6�� l3v� /�s �vrlr re9�z %�3-3�3 C� Were sewage odors detected when arriving at the site(yes or no): P3ae 7 of I I OFFICIAL MISPECTION FORM—NOT FOR VOLUNTARY ASSESSl NTS S SU A.CE SEWAGE DISPOSAL SYSTEM E'4SPECTION EOM PART C SYSTEM D4FORM TION(continued) Property Address:/3`1 C 6 AF'S' —174 4 i �-- aGU�sT �AR�srsjr3�� Owner- Date of Inspection: :3 o BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_ 44cast iron _ PVC_other(explain): Distance from private water supply well or suction line: osr` /op Comments(on condition of joints,venting,evidence of leakage,-etc.): SEPTIC T ANW:—(locate-on site plan) el Depth below grade: :Material of construction:—cow'ncrete metal _otherexplain — fi --polyethylene polyethyiene r — If rant:is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy certificate) Dimensions: Sludge depth: Distance from top of sludgy to bottom of outlet tee or baffle: 2 Scum thickness: 3" ' Distance-from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ^.r,95&k ST­c�- Comments(on pumping recommendations,inlet and outlet tee or bale condition,structural integrity, liquid la­r is as related to outlet hivert,evidence of.leakage,etc.): GREASE TRAP:—{locate on site plan) Depth below grade:_ �Niaterial of construction:- ncrete m 1 fiberglass_polyethylene—other {e:;cplain); :Dimensions: Scum thickness: Distance from top of scum to top utlet tree or baffle: Distance from bottom of scum t o m of cutlet tee or baffle: Date of last pumping, Comments(on pumping re m mendatio inlet and outlet tee or baffle condition,structural integrity,liquid le As as related to outlet inve' vidence ofleakab etc.): Page8ofli INSPECTION FORM NOT FOR VOLUN T'ARy S �,..,.. �N SUBSURFACE SEWAGE,DISPOSAL SYSIMM INSPEcTION FORM. - PART C S V-STEW1 INF ON(tominued) Property Address: f 3 9 �i9PBS /2gi ��S57 B�`I.✓S79 6�� Date of tiara: p TIGHT orHOLDING TANK: (tank must be pumped at f une of inspecti(m)('locate on site pima) Depth below grade: !Aaterial of. ,Cons Il: r concrete meta fiberglass_polyeLhyle: cstlrer(explair±): Dimensions: Capacity: q ons Design Flow: ortslda} darn present(yes or no): Alarm level: arm in weric:n . -der(yes or no).- Date of last pump Comments{ rtion of alarm.and float switches, ic.): SOX: {if present must be opened)0ocate on site plan) :Depth of liquid level above outlet insert: Corn tents{note if box is level and distribution to outlets cquai,._&9y e�Adence of solids tarryover,any evider-re of 1jeakage into or out of box,etc 6 O/c nJ-M 3 CHAMBER: (locate on site plan' Pumps in working order{yes or o). Alarms- in working order(_yes o no): Coib-metits(note tondition of !pump c ben vanditivn ref pumps aid zoiktehantzs,at.)_ i Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Owner Date of Inspection: SOIL ABSORPTION SYSTEM SAS.: L� (SAS): (locate on site plat4excavation not required) _ If SAS not located explain wh G24 T 7e/hing pits,number: ` leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: Overflow cesspool,number innovative'/alternative systenr Type/name of technology: Comments(note-condition of soil,signs-of hydraulicfailure,level of ponding,damp soil,condition of vegetation, , etc.): CESSPOOLS: (cesspool must be p ped as part of inspection)(locate on site plan) Number and configurati n: Depth—top of liquid to let invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwate tnflo (yes or no): Comments(note condit-'on of soi,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on s plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of il,signs of hydraulic.failure,level of ponding;condition of vegetation,etc.): i I : Page 10 of 11 OFFICIAL,_INSPRCTLON FORM—NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAI._SYSTEALINSPE N FORM PART C SYSTEn-INFORMATION(continued) Property Address:'/3 Owner:�e2sCe Date of Inspectioaa: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at-least two-permanent reference landmarks or benchmarks.Locate ail wells within 100 feet Locate where public water supply-entersthe-building. W yl �qc f� jo 0 13D = /b6 v raze 1 I of 11 0i�CI EgSPECTION FORM—NOT FOR VOLUNTARY ASSESSMZNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM &O /SON(continued). rr' open ty Address_ 3 mil' L iJ 6'E s /44 SI .:EXAM Slope .Su-face;pater C heck cellar Shallow webs r Estimated depth to ground water � �feet P_lease �indicate(check)all methods used to determine the high ground water elevation: _(/ Obtained from system design plans on record-If checked,date of design plan reviewed:_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ---Checked with local excavators_installers-(attach documentation) Accessed USGS database-explain: Jou must describe how you establisbed the nigh gro`v water elevation: �� GvsrTA4L 7 Cal r�c�/ TOWN OF BARNSTABLE LOCATION �� q C�G�l�P_5 1,Ko ! ; SEWAGE # — 3 ,30 VILLAGE �a�STCe 6�e �C . ASSESSORS MAP & LOT INSTALLER'S NAME & PHONE NO. �j i /� �v�rl,-a le of SEPTIC TANK CAPACITY /DOD 4� LEACHING FACILITY:(type) e g :� � (size) p O O NO. OF BEDROOMS 3 P,RIVATE WELL OR PUBLIC WATER /Z/pl/ 1 BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r o s � r , v n; { r F6 r, :5Y Calms U11fl FLAV4 t ry CI r a _. t 24k A111X a hstj Cat TC C_r),NR CLAP'".P'— j -F f -x$ wATL9 Til51 9 _._. ti C tip \ SCALE DMTE 508.428 •6191 (8evI i n L�1�C7 Fu�,�tti c, @UStO1'111 I - nLs� Rn±t - o e S l g n 5 copyright C) 7992 —._ All Rights 1 Reserved - A5914 r� Jj I= j r ,a i { 24x24{N aUl:Gi1. hii l I MULLIOl'i T .. \vP1Tt GEnnFZ SH1NCtr ES d nar fans and layouts b D.C.D.are for the use of their customers„ only : Any other use is strictly rohibited ` _ f'r e� mi y. p y Y P I .,. ,. 777 7`771 • , w . 'q -o t2 PL`AN tZ• `` 12 R.3Cs tNSvL.: ,. Zx4 Cu:.jatsTs _t w I Et Rg .K k ' � , it2 Sty.-. . 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F customers t� other cle is Stri :.tl` prohibited EPreliminary ans and to outs by GC D ire , :�r the use o tt,e+ r �ustome only _ anti o �� ,� l � P PI y :NEW fNrLRNO R[P-'JGRAF"'hl7C3 It ":c'v,.'�r'^ ; a 4s 1-b s i _ F {�`-Co �2-{Q � �r 2-S ? f2•p Al 3 t , 5° ' - , m ( tr)F,CCJN 1�'•c�} 2.2 4 .0 2.4 t•,•8 , 2a 1 - t- • 1 � y , : � r , I 14 •b ' M �( f SCALE vPEP% DATE ,. II ' * ' —r 1 3 3„ 508.428.6191 � 4,. wJ !! i Y _ K1T _ _ h1N11-4 G , 1 1 M { Custom • o es igns 1 I `2 copyright © 1992 } m , i All Rights , z , 9 Reserved -0t-Jc.S.n��v./ -} 1 ; , , � _; ----�----$ �t<�au r�.tc�u-t.A�t r���r,� tV t � I - 1 '_0 0 - i I r' i M I ) •20 ` � � 1 I 1 .l 5 4> , P I 2� 2a t I I z t, N i � I , f LI Q t I P t•i � I I -1 t o T 7i n l : , 5u P-E R 1 SCALE DATE p � ftfD ; , i _ zC 508.428 6191 I` I I ' K CIS` I� i 1T ' ` , rj�8 �-•C.:( Jut:-��i.cr ----------'--- , `'Y d . : (Eevi • C3 eV I) i 2� 4 t rltn I @Ustom I a esigns 2 copyright © 1992 i f ; All Rights 9 ---__..::_ _ � Reserved y FLLA r I fZG—U\ Patti4,� cm R 8. ' i (v Q �y LO i ►Y1 tf 2° • -Ca 4` a 4`•C, 5'.Co ' s 4 b i - Pr eliminary plans and ,Iayouts by D.C.D.are for the :use of thei r customers only . Any.'other use is strictly prohibite ENGLANO REPPOGPAPHICS&SUPPLY CO < ;: